Recently I have had two clients referred to me for individual therapy, by therapists who had worked with the client and his/her spouse in couples’ therapy. In both instances the referring therapists explained that the clients had “individual issues” which “needed” to addressed in order for the client to be able to work on their relational issues. Both therapists stressed that the couples’ therapies were not proceeding well: in one instance the spouses were extremely hostile towards each other, while in the other instance the therapist identified how one of the partners had issues stemming from his childhood that needed to worked through in order for the client to effectively participate in marital therapy (the therapist planned to work with this individual and referred the spouse to me for individual therapy).
However, when I met with each of the individual clients both described the primary source of their problems as their relationships. One client, detailed how he was very upset by how his partner treated him: called him names, did not help at home, and was generally inconsiderate. He reported thinking, at times, that he might be “a little depressed” but he clearly stated that the main source of his upset was his relationship and how he was treated. Similarly, the second client detailed how she was very upset by the state of her marriage. She reported that her husband berates her over little things (no physical violence), accuses her of having anger problems, and will not be sexually intimate with her. She acknowledged that she does have “issues” of her own. Specifically, she noted that she does get angry (verbally) with her partner and will yell at him when she is being yelled at. While she detailed childhood issues with her father she stressed that her primary concern was the deplorable state of her marriage.
In both instances the clients who had been referred for individual therapy expressed confusion about the referral and made comments that raised questions about the appropriateness of individual therapy. The male client stated that his partner only would go for individual therapy if he went as well, and that he was coming for therapy in hopes that his partner would go to therapy and work on her issues. In the case of the female client, she expressed confusion about the referral for individual therapy. She talked about how she and her partner had argued quite angrily in the couple’s sessions, particularly just prior to the referral, but noted that she wanted to work on the couples’ issues. The therapist who referred the later client did state, when making the referral, that the therapist did not think that the couple could talk productively in co-joint sessions.
Clearly, how therapists proceed, the modality we each choose, is influenced/dictated by our treatment model/approach, personal beliefs, and assumptions about human nature. My systems approach leads me to involve spouses, partners and family members in treatment, and focus on patterns of interaction/current relational issues. More individually oriented therapists focus on the individual: patterns of thinking for CBT therapists, values and self-regulation for ACT therapists, past trauma and lost for Trauma Informed therapists, and history and past experiences (particularly relational) for more psychodynamic therapists, and so on.
However, when considering which treatment approach to utilize/recommend it also behooves us to take into account clients’ needs and preferences. The issue of preference should also be paramount when considering or recommending a change in modalities, particularly if this recommendation is coming from the therapist rather than being requested by the client. Therapists need to ask themselves: why am I recommending the change in modalities, is the modality or my ability to effectively work with this client/clients the problem, how will the clients experience a recommendation for a change in approach? Clients may feel rejected or abandoned if therapists recommend a change in modality. In the case of the male client, he noted that his wife had said “you’re abandoning us” when the therapist referred each of them to individual therapy. Moreover, clients may interpret such referrals as meaning that their marriage is not workable or viable.
When couples therapy is not progressing/when couples are at an impasse we need to be open to the idea that changing modalities may not always be the best option. Obviously, there are cases where this would be true, such as one spouse having an untreated and active addiction, or one spouse continuing an affair. However, in most instances it would seem more appropriate to discuss the lack of progress with the couple and to evaluate our own ability to effectively assist a given couple. It is quite possible that changing clinicians may be a better option than changing modalities. It also is critical to discuss the lack of progress with clients, as such a discussion may help clients address their lack of progress more effectively, i.e., identify what else they need from therapy and the sources of their difficulties making progress.
The research on psychotherapy outcome strongly supports the idea of finding the approach and therapist that best fits for a client rather than trying to fit the client to a school of therapy. The issue of best fit is particularly salient for couples therapy as this type of therapy is often extremely challenging. While it is difficult for most of us to acknowledge when we are not helping a given client (individual, family or couple) we need to be aware of the fact that no one helps everyone. Being open to discussing impasses in treatment, and even considering a different therapist as an option, will likely benefit the couples we work with more than trying to push them to work on issues that are not salient to them, at the time.